Building new hospitals: a UK infection control perspective.

Infection control input is vital throughout the planning, design and building stages of a new hospital project, and must continue through the commissioning (and decommissioning) process, evaluation and putting the facility into full clinical service. Many hospitals continue to experience problems months or years after occupying the new premises; some of these could have been avoided by infection control involvement earlier in the project. The importance of infection control must be recognized by the chief executive of the hospital trust and project teams overseeing the development. Clinical user groups and contractors must also be made aware of infection control issues. It is vital that good working relationships are built up between the infection control team (ICT) and all these parties. ICTs need the authority to influence the process. This may require their specific recognition by the Private Finance Initiative National Unit, the Department of Health or other relevant authorities. ICTs need training in how to read design plans, how to write effective specifications, and in other areas with which they may be unfamiliar. The importance of documentation and record keeping is paramount. External or independent validation of processes should be available, particularly in commissioning processes. Building design in relation to infection control needs stricter national regulations, allowing ICTs to focus on more local usage issues. Further research is needed to provide evidence regarding the relationship between building design and the prevalence of infection.

Development of an internal quality assessment scheme in a clinical bacteriology laboratory.

AIM: To develop an internal quality assessment (IQA) scheme in a clinical bacteriology laboratory. METHODS: Over 24 months, 1230 diagnostic specimens, representing 0.42% of laboratory workload, were anonymised and resubmitted for analysis. Six hundred and twenty one (48.7%) of these gave positive culture results; 44 fecal and upper respiratory specimens were "spiked" (artificially inoculated) to increase the proportion of positive samples. RESULTS: Discrepancies between IQA and clinical sample results occurred in 188 cases (14.8%): 76.6% of these were in culture results, 13.3% in microscopy performance, and 10.1% in clerical recording. The culture discrepancy rate for each positive sample was lowest for wound (17.5%) and urine (18.1%) specimens, and highest for faeces (34.9%) and upper respiratory (37.7%) samples. Discrepancies in several areas responded to staff training and improvement in technical methods. CONCLUSIONS: An IQA programme of this type assesses the reproducibility of tests within a diagnostic laboratory when analysing common specimen types and organisms. It permits blind assessment of many areas of diagnostic work that are not readily amenable to other quality assurance methods, and it raises the awareness of all staff to the importance of quality in every aspect of specimen and data processing.

A rapid micro-agglutination technique for the detection of antibody to Legionella pneumophila serogroup 5.

A rapid micro-agglutination test (RMAT) for the detection of antibody to Legionella pneumophila serogroup 5 is described. It was found to be both sensitive and specific when compared with the indirect immunofluorescence test. Evaluation of 89 paired sera from patients with respiratory symptoms showed that the incidence of L. pneumophila serogroup 5 respiratory infection in East Anglia is low: only one case was found in this study. The RMAT would be easy to perform as a screening test in a routine serological laboratory.

A district general hospital's method of post-operative infection surveillance including post-discharge follow-up, developed over a five-year period.

We report on a post-operative infection surveillance system which includes post-discharge follow-up, developed over five years in a district general hospital in the West Midlands, UK. The methods used for following up 667 patients undergoing one of five representative surgical procedures are described. Emergency, elective and day-case procedures are included. A combination of healthcare worker questionnaire, telephone calls and patient questionnaire gave a follow-up rate of 92.7%. The system took infection control staff an average of 40 min per patient (30 min inpatient assessment, 10 min post-discharge). Almost half (48%) of surgical site infections were diagnosed after discharge from hospital. The system worked equally well when conducted as part of the UK Nosocomial Infection National Surveillance Scheme (NINSS), or as in-house projects. It is likely that the system could be used in other areas with similar population characteristics and support from local general practitioners working in the community.

An epidemiological study after a water contamination incident near Worcester, England in April 1994.

STUDY OBJECTIVES: To investigate whether exposure to tap water contaminated in a major river pollution incident with 2 ethyl 5,5 dimethyl 1,3 dioxane (EDD) and 2 ethyl 4 methyl 1,3 dioxolane (EMD) was associated with an increase of self reported symptoms. To assess the extent of association between noticing the water had an unusual taste or odour and self reported symptoms. DESIGN: Retrospective cohort study. SETTING: A city and two nearby towns in a semi-rural area of England, UK. PARTICIPANTS: A total of 3861 people who replied to a postal questionnaire asking about symptoms and water consumption sent to a sample of 1000 households in each of three areas--one area supplied with contaminated water (study group) and two control areas that were unaffected (control groups). MAIN RESULTS: The household response rates were 65% for the study group and 56% and 57% for the two control groups. Self reporting of 10 individual symptoms was significantly increased in the study group compared with controls. Within the study group, reporting of one or more symptoms was significantly higher in subjects who consumed contaminated water but not among subjects who used it to wash or cook. Subjects who drank contaminated water showed a dose-response relationship for self reporting of one or more symptoms and for seven individual symptoms. Within the study group, however, only 62% (867 of 1398 subjects) noticed that the water had an unusual taste or odour. Among subjects who did not notice that the water had an unusual taste or odour, no association was found between drinking contaminated water and reporting one or more symptoms, or between drinking contaminated water and reporting of individual symptoms, although a dose-response relationship was shown between the amount of water consumed and self reporting of nausea. Among subjects who noticed the water had an unusual taste or odour, both an association and a dose-response relationship were found between consumption of contaminated water and the self reporting of six symptoms--diarrhoea, nausea, headache, stomach pains, skin irritation, and itchy eyes. CONCLUSIONS: Higher rates of symptom reporting were associated with the water contamination incident. Reported symptoms seemed, however, to be associated with the ability to detect an unusual taste or odour in the water. Because concentrations of the contaminants would be expected to be evenly distributed in the tap water in the affected area, irrespective of taste or odour, and because of the known toxicity of the parent compounds of EMD and EDD, it is concluded that the increase in self reported symptoms in the study group respondents was associated with noticing the unpleasant taste or odour of the tap water and not with the chemical contamination. It is concluded that the observed increase in reporting of nausea with increasing water consumption was due to public anxiety caused by the incident but did not pose a serious risk to the public's health. The increase in self reported symptoms in the area affected by the contamination was an important reminder of the wider health implications of "health scares".

Prevention of infection by ciprofloxacin in neutropenia.

Ciprofloxacin with erythromycin, each at a dose of 250 mg 12-hourly, is effective prophylaxis against Gram-negative bacteraemia in neutropenic patients. The erythromycin component may contribute little to prophylaxis and does select for erythromycin-resistant viridans streptococci which then cause bacteraemia. Ciprofloxacin prophylaxis does not prevent coagulase-negative staphylococcal bacteraemia and resistant strains are selected. Initial use of vancomycin with a ureidopenicillin in pyrexial patients is currently justified by the exclusively Gram-positive nature of breakthrough bacteraemia. In patients failing to respond to this regimen, treatment modification to include full-dose amphotericin is frequently effective. Surveillance and containment isolation of patients carrying resistant Gram-negative species is prudent to prevent the spread of such resistant bacteria in oncology/haematology units.